Peripilar Sign in Androgenetic Alopecia: Does It Really Indicate Peripilar Infiltrate?

INTRODUCTION: Peripilar sign (PPS) is a trichoscopic sign that was first described in androgenetic alopecia (AGA) and is thought to reflect the presence of perifollicular infiltrate (PFI) in histopathology. OBJECTIVES: To study PPS in a cohort of patients with AGA and to assess its validity as a sign indicative of PFI. METHODS: One hundred patients with AGA (confirmed by trichoscopic examination) were recruited in this cross-sectional study. From those patients, frontal scalp biopsy was done for two subgroups, 22 patients with PPS and 23 patients without PPS. Both groups were compared as regards the presence of PFI. RESULTS: Peripilar sign was present in 50% of the 100 studied cases. No significant difference existed between those with and those without PPS as regards PFI. Peripilar sign was significantly more encountered in patients with skin type III (p=0.001). Its absence was significantly associated with lower interpretability of yellow dots (p<0.001) and their scores were significantly positively correlated (r=0.498, p<0.001). Peripilar sign was significantly associated with absent melanophages histopathologically (p=0.011). CONCLUSION: Peripilar sign as a trichoscopic sign in AGA does not reflect PFI. It represents a dark color more encountered in patients with lighter skin types. This can be explained by the increased contrast between the dark PPS and the lighter surrounding skin in lighter skin types. Further studies using melanocyte markers and Masson Fontana's stain are needed to further verify the cause of this peri-follicular dark color.

Comparison of vascular endothelial growth factor expression between lesional and non-lesional skin in patients with morphea: a dermoscopy-guided immunohistochemical study.

Morphea is an inflammatory fibrosing disease, initiated by vascular injury resulting in increased collagen formation and decreased collagen degradation. This study was designed to evaluate the role of angiogenic vascular endothelial growth factor (VEGF) in the vascular changes which are dermoscopically evident in morphea lesions, compared with that in non-lesional skin, by assessing its expression immunohistochemically on tissue blood vessels. Twenty patients with morphea were subjected to clinical and dermoscopic examinations. Two skin biopsies from lesional and non-lesional skin were obtained and stained with hematoxylin and eosin (H&E) and immunohistochemically with VEGF. Dermoscopic examination showed linear blood vessels in 90% of the lesions. No significant difference in the number of VEGF-stained and unstained blood vessels, was observed between the lesional and non-lesional skin (p = 0.475 and 0.191, respectively). A weak inverse correlation was found between the total number of blood vessels positive for VEGF and the disease duration, (r = - 0.48; p = 0.032). Significant differences were found between different stages of morphea and total number of blood vessels negative for VEGF, (p = 0.017). In conclusion, VEGF immunostaining, which represents the newly formed blood vessels, showed no difference between lesional and non-lesional skin in patients with morphea. Thus, the dermoscopically observable blood vessels in lesions compared with non-lesional skin are not due to angiogenesis, but rather due to the thinning and atrophy of the overlying epidermis in morphea cases, rendering the blood vessels more obvious.

International Dermoscopy Society criteria for non-neoplastic dermatoses (general dermatology): validation for skin of color through a Delphi expert consensus.

BACKGROUND: The International Dermoscopy Society (IDS) recently released a set of five basic dermoscopic parameters (vessels, scales, follicular findings, "other structures," and specific clues) encompassing a total of 31 subitems to standardize the use of dermoscopy in non-neoplastic dermatoses, yet they have been developed taking into account Caucasian/Asian skin, with consequent possible limitations if used in dark skin. OBJECTIVES: To validate the abovementioned criteria for the use in dark-skinned patients (phototypes IV-VI) through an expert consensus. METHODS: The two-round Delphi method was adopted, with an iterative process consisting of two rounds of email questionnaires. Potential panelists were recruited via e-mail from all over the world based on their expertise on dermoscopy of non-neoplastic dermatoses in skin of color. RESULTS: Twenty-two panelists took part in the validation process. All of the five originally proposed parameters and subitems reached agreement during the first round, aside from "follicular red dots." Additionally, during round 1, five new subitems were proposed (perifollicular scales distribution, follicular openings obliteration, broken hairs, eccrine pigmentation, and eccrine ostia obliteration), along with the possibility to change the denomination of parameter 3 (from "follicular findings" to "follicular/eccrine findings") and split it into two subparameters ("follicular findings" and "eccrine findings"). All such proposals reached agreement during the second round and therefore were included in the final list, for a total of 37 items. CONCLUSIONS: Although nearly all the dermoscopic criteria originally proposed by the IDS are applicable even to darker phototypes, several additional variables need to be assessed.

Entodermoscopy Update: A Contemporary Review on Dermoscopy of Cutaneous Infections and Infestations.

Infectious cutaneous diseases are very common, especially in certain geographic and tropical regions. Sometimes they may simulate other dermatoses, ordering verification of diagnosis with particular investigations. Dermoscopy is among one of the most important tools readily available in the outpatient setting for the dermatologist to confirm the diagnosis. In this up-to date review, literature concerning the various dermoscopic features of parasitic, viral, dermatophytic and bacterial cutaneous infections is composed. In addition artefacts as well as practical issues in dermoscopy usage are discussed; with the aim to empower dermatologists to promptly and non-invasively diagnose and manage cutaneous infections and infestations.

Dermoscopy in general dermatology (non-neoplastic dermatoses) of skin of colour: a comparative retrospective study by the International Dermoscopy Society.

BACKGROUND: Dermoscopy has been shown to be a useful supportive tool to assist the diagnosis of several non-neoplastic dermatoses (i.e. inflammatory, infiltrative and infectious skin diseases), yet data on skin of colour is still limited. OBJECTIVES: To characterize dermoscopic features of non-neoplastic dermatoses in dark-skinned patients in order to identify possible clues that may facilitate the differential diagnosis of clinically similar conditions. MATERIALS & METHODS: Members of the International Dermoscopy Society were invited to submit cases of any non-neoplastic dermatosis developing in patients with Fitzpatrick Phototypes V-VI whose diagnosis had been confirmed by the corresponding gold standard diagnostic test. A standardized assessment of the dermoscopic images and a comparative analysis according to clinical presentation were performed. Seven clinical categories were identified: (I) papulosquamous dermatoses; (II) facial hyperpigmented dermatoses; (III) extra-facial hyperpigmented dermatoses; (IV) hypopigmented dermatoses; (V) granulomatous dermatoses; (VI) sclerotic dermatoses; and (VII) facial inflammatory dermatoses. RESULTS: A total of 653 patients (541 and 112 with Phototype V and VI, respectively) were recruited for the analysis. Thirty-six statistically significant dermoscopic features were identified for papulosquamous dermatoses, 24 for facial hyperpigmented disorders, 12 for extra-facial hyperpigmented disorders, 17 for hypopigmented disorders, eight for granulomatous dermatoses, four for sclerotic dermatoses and 17 for facial inflammatory diseases. CONCLUSION: Our findings suggest that dermoscopy might be a useful tool in assisting the diagnosis of clinically similar non-neoplastic dermatoses in dark phototypes by revealing characteristic clues. Study limitations include the retrospective design, the lack of a direct dermoscopic-histological correlation analysis and the small sample size for less common diseases.

Can basal cell carcinoma lateral border be determined by fluorescence diagnosis?: Verification by Mohs micrographic surgery.

BACKGROUND: The preferential accumulation of 5-aminolaevulinic acid (ALA)-induced protoporphyrin IX (PpIX) in neoplastic cells supports its potential use in the photodetection of epithelial tumours through porphyrin fluorescence. OBJECTIVE: To assess the validity of fluorescence diagnosis (FD) as an efficient pre-surgical in vivo imaging tool for defining the lateral boundaries of various types of basal cell carcinomas (BCCs). METHODS: The BCC tumour area was determined for 27 patients using FD digitalized imaging system, where the accumulation of PpIX in tumour tissue in relation to normal tissue was measured. Subsequently, BCCs were excised according to the complete area defined by FD using Mohs micrographic surgery (MMS). RESULTS: Of the 27 BCCs, the FD margin of the lesion coincided with the histopathological picture in 12 BCCs (44.44%). The mean value of accumulation factor (AF) was 2.7. Although 17 pigmented BCCs showed attenuated or absent fluorescence in the center, fluorescence at their periphery was used as a guide for excision, and statistically, the pigmentation of the BCCs showed no effect on the results of the FD efficacy (p=1.0). CONCLUSION: Fluorescence diagnosis of BCC may be beneficial as a guide to the safety margin needed before MMS. The safety margin is decided according to the FD tumour diameter in relation to the clinical tumour diameter.

Evaluation of Angiogenesis in Early Mycosis Fungoides Patients: Dermoscopic and Immunohistochemical Study.

BACKGROUND: Angiogenesis is the production of new blood vessels from an existing vascular network; it plays a critical role in solid tumor development and metastasis. OBJECTIVES: To assess angiogenesis in early cases of mycosis fungoides (MF) and to determine vascular patterns in MF dermoscopically. METHODS: 25 patients with MF and 20 healthy controls were included. The MF lesions were assessed dermoscopically. CD34 immunohistochemistry was performed to count dermal microvessel density (MVD). RESULTS: The total dermal MVD was significantly higher in MF patients (19.77 ± 5.81) than in controls (4.44 ± 3.16; p = 0.013). Among them, there were 10.8 ± 4.1 sprouts of endothelial buds (clusters of cells per field) in patients and 2.4 ± 2 in controls (p = 0.000). The dotted pattern of blood vessels was the most frequently encountered pattern in the MF lesions by dermoscopy. CONCLUSIONS: Our findings support that neoangiogenesis is significantly increased in early MF lesions and that the main dermoscopic feature of MF is dotted blood vessels.

Clinical effects of "pioglitazone", an insulin sensitizing drug, on psoriasis vulgaris and its co-morbidities, a double blinded randomized controlled trialx1.

OBJECTIVES: To evaluate the therapeutic efficacy of pioglitazone on psoriasis vulgaris and its comorbidities. MATERIALS AND METHODS: Forty-eight patients with moderate-to-severe psoriasis vulgaris were enrolled in this randomized double blinded placebo-controlled trial. Active treatment included: oral pioglitazone 30 mg daily for 10 weeks. Primary outcome (treatment success) was PASI-75. Secondary outcomes included changes in metabolic syndrome, insulin resistance and cardiovascular risk. RESULTS: Treatment success was achieved in 5/24 (21%) in the pioglitazone group compared to 1/24 (4%) in the placebo group; however, this difference was not significant (p = 0.081). Compared to placebo, no significant difference existed as regards high-sensitive C reactive protein. Metabolic syndrome and insulin resistance were not affected. CONCLUSIONS: This short term (10 weeks duration) study revealed no effect of pioglitazone 30 mg daily neither on the clinical response of moderate-to-severe psoriasis nor on metabolic syndrome and insulin resistance. Cardio-protective role appears to be more related to improvement of psoriasis. LIMITATION: Short duration of treatment and small number of subgroups.

Does fluorescence diagnosis have a role in follow up of response to therapy in mycosis fungoides?

BACKGROUND: Monitoring of tumor burden during mycosis fungoides (MF) treatment, is crucial to adjust therapy accordingly. This is usually achieved through combined by clinical assessment with histopathological and immunohistochemical evaluation. AIM: To assess the validity of fluorescence diagnosis (FD) in the measurement of response to therapy in early MF, using in comparison flow cytometric technique of skin biopsies for CD4+/CD7- malignant T-cell count before and after therapy. PATIENTS AND METHODS: Twenty-two patients of histologically proven early MF (stages Ia, Ib, IIa) were subjected to fluorescence diagnosis of their most affected skin lesion before and after 12 weeks of phototherapy with or without combination therapy. In comparison flow cytometric assessment of skin biopsies for CD4+/CD7- malignant T-cell count was evaluated before and after therapy from skin biopsy of the same lesion. RESULTS: All tested MF lesions showed varying degrees of fluorescence by FD at week zero, with a mean accumulation factor (AF), which is the fluorescence ratio between the tumor tissue and normal skin, of 2.2. After 12 weeks of therapy, the mean AF showed significant reduction to 1.94 (p=0.009). The percent of CD4+/CD7- cells dropped significantly after treatment (p=0.029). No correlation between CD4+/CD7- cell counts and the mean AF could be deduced. CONCLUSION: In cases of mycosis fungoides, fluorescence diagnosis can represent an effective tool for evaluating the response to therapy. Changes in accumulation factor values can be used for follow-up of therapy in the same patient, but it should not be used as an absolute value.

An immunohistochemical study of laminin in basal cell carcinoma.

BACKGROUND: Laminins are components of the extracellular matrix that mediate cell adhesion, growth, migration, proliferation and differentiation. Basement membrane (BM) laminins, in particular, may play a role in enhancing carcinoma cell motility. AIM: To evaluate the distribution pattern of laminin in basal cell carcinoma (BCC), as regards the basement membrane, cellular cytoplasm, peritumoral lacunae and surface epithelium and to correlate laminin distribution with different variants of BCC. PATIENTS AND METHODS: Skin biopsy specimens were obtained from 21 BCC patients for routine histopathological and immunohistochemical study. Laminin was evaluated qualitatively and semiquantitatively using monoclonal mouse antihuman antibody (Dako-Laminin, 4C7. Code No: MO638, which reacts with the terminal globular domain of the α5 chain) RESULTS: The majority of BCC cases showed patchy cytoplasmic distribution of laminin. The BM expression of laminin, in most cases, was well defined, fine and linear with irregular areas of thickening. Staining intensity was moderate in differentiated and mixed variants, weak in superficial spreading and absent in morpheic types. CONCLUSION: Cytoplasmic and basement membrane laminin is important in the pathogenesis and invasion of BCC. Most laminin was in basement membrane zone (BMZ), and the more differentiated the tumor, the more cytoplasmic and BM staining it expressed.

Topical calcineurin inhibitors in atopic dermatitis: a systematic review and meta-analysis.

OBJECTIVES: To build a critical appraisal of the available literature to evaluate the effectiveness of topical calcineurin inhibitors in treatment of atopic dermatitis (AD), in comparison to topical corticosteroids (TCs) and/or placebo. DESIGN: systematic review and meta-analysis. DATA SOURCES: electronic search of MEDLINE Pubmed along the last 10 years (1997-2006). STUDY SELECTION: randomized control trials of TCIs reporting efficacy outcomes, in comparison to TCs or vehicle (placebo) or both. DATA SYNTHESIS: of 210 articles, 19 studies were included, 10 for tacrolimus and 9 for pimecrolimus, involving 7378 patients of whom 2771 applied tacrolimus, 1783 applied pimecrolimus, and 2824 were controls. Both drugs were significantly more effective than a vehicle. However, two long-term trials comparing demonstrated the value of pimecrolimus in reduction of flares and steroid-sparing effect after 6 months. Compared to TCs, both 0.1% and 0.03% tacrolimus ointments were as effective as moderate potency TCs, and more effective than a combined steroid regimen. Tacrolimus was more effective than mild TCs. CONCLUSIONS: TCIs in AD are more effective than placebo. Although less effective than TCs, pimecrolimus has its value in long-term maintenance and as a steroid-sparing agent in AD, whenever used early enough, at first appearance of erythema and/or itching. In treatment of moderate to severe AD, topical tacrolimus is as effective as moderately potent TCs, and more effective than mild preparations. Chronic AD lesions of the face and flexures are the most justified indication for topical calcineurin inhibitors.

Microscopic study of normal skin in cases of mycosis fungoides.

BACKGROUND: During therapy of patients with mycosis fungoides (MF) at the Department of Dermatology, Kasr El-Aini Hospital, follow-up biopsies are routinely taken every 2 months. It was noticed that lesions of MF might become clinically normal during treatment, and yet still show microscopical evidence of MF. This finding raised the possibility that clinically normal skin in MF could be microscopically involved. AIM: The aim of our work was to evaluate the degree of histopathological involvement of normal-looking skin in patients with MF. PATIENTS AND METHODS: Thirty patients with stage IB were biopsied from their normal skin. Two biopsies were taken: one proximal (2 cm) and the other distal (> 5 cm) from any visible lesion. Ten normal controls were included in the study. All specimens were stained with H&E and examined microscopically. The microscopical diagnosis was confirmed by immunophenotyping. RESULTS: Epidermotropism was detected in 21 (70%) of the proximal skin biopsies and 14 (47%) of the distal skin biopsies, whereas no biopsy from the control group showed epidermotropism. All the proximal skin biopsies showed dermal infiltrate and 90% of the biopsies from the distal normal skin showed dermal infiltrate (mostly superficial perivascular). CONCLUSION: Normal skin in patients with MF could be affected microscopically and this may raise questions regarding the credibility of the current staging classification of MF, and may necessitate taking biopsies from normal skin before starting topical treatment. During MF treatment, biopsies from cured lesions are required before starting withdrawal.